Hygiene

Sample note:
Periodontal maintenance

Perio maintenance with charting, localized 5 mm pockets, and recall decision. Transcript on the left, the note as it appears in CareNotes on the right.

Hygienist visit with a periodic exam by the dentist. Perio measurements were spoken during probing. No built-in procedure type, so Tx is narrative only. Names, dates, and identifying details are fictional; the encounter is a composite written for illustration.

What was said

Excerpt. Speech-to-text ran on the phone; this text is all that left the device.

Hygienist: Hi, good to see you. Any changes to your health or medications? Still on the Fosamax?

Patient: Yes, same. Nothing else. We just got back from seeing the grandkids in Denver.

Hygienist: Oh nice. Four bitewings today, you're due. Let's do your perio chart. Upper right, two three two, three two three, three two four, four three three, bleeding on the distal there...

Hygienist: Lower left, nineteen, five four three, bleeding, nineteen's still that five on the distal, same as last time. Eighteen, four three three.

Hygienist: Oral cancer screening, everything looks normal. Head and neck fine, TMJ no issues. Tissue's a little red around the lower molars, light bleeding generalized, moderate calculus lower front, light stain.

Hygienist: Doing your perio maintenance, ultrasonic and hand scaling, I'll irrigate the lower left where it's deeper. Topical gel on the gumline. Polishing. Fluoride varnish, okay with that? Great.

Hygienist: Your home care is good. Keep the water flosser nightly, and with that five millimeter spot I want to keep you at every three months.

Dentist: Hi there. Exam looks good, no new decay on the x-rays. Agree with three months. I'm watching the recession on number six, no treatment needed today.

What CareNotes wrote

The generated note in the CareNotes note viewer, before the clinician's edits and signature. It is interactive.

Robert K.

Side Note:
Just back from visiting grandkids in Denver.
Pt CC:
Perio maintenance, periodic exam
RMH:
Alendronate (Fosamax). NSC.
All risks, complications, alternatives, and benefits discussed, all questions answered.
Exam:
4 BWX, no new interproximal caries. EOE/IOE WNL. OCS negative. TMJ WNL. Full mouth probing: generalized 2 to 4 mm, localized 5 mm #19D unchanged from last visit with BOP, BOP #3D. Recession #6, watch. Plaque light generalized. Calculus moderate mandibular anterior lingual, light elsewhere. Light extrinsic stain. Light generalized bleeding, localized mild erythema mandibular posterior. Periodic exam by dentist: no new carious lesions, #6 recession no tx today.
Tx:
Topical gel along gingival margins. Perio maintenance full mouth, ultrasonic + hand instrumentation. Localized subgingival irrigation LL posterior. Polished. 5% NaF varnish applied, pt consented. OHI: home care good, reinforced nightly water flosser and interproximal cleaning at #19. Perio status stable, localized 5 mm #19D persists.
NV:
3 month perio maintenance.
Dr. Rivera

How the pills work

No procedure type was selected for this visit, so the Tx section is the AI's narrative alone. When a built-in procedure is selected, CareNotes adds a one-line structured sentence with tappable choices; see the composite, root canal, or extraction sample.

How it lands in the chart

On the free tier the clinician copies this note from the app or carenotes.ai/notes and pastes it into the patient's chart in any practice management system. On Premium the same note is uploaded into the chart in Open Dental, Dentrix Ascend, Eaglesoft, or Curve after the clinician taps Ready to Upload. Headings, order, and wording follow the office's own template; the Progress Note template above is the default.

What to look for

Tooth numbers and surfaces are carried from speech into the note. Anesthetic, carpule count, and technique are written out. Materials and shades are named. The medical history review, consent line, post-operative instructions, and next visit are present even when they were said in passing. Personal details the patient mentioned go to Side Note so the doctor remembers them next time. Anything not said is not invented; if a dose or a step is missing from the recording, the clinician adds it on review.

Record one visit and compare

Core notes are free with no cap. Use your own template or start with the default.